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ST-elevation myocardial infarction

What's new

The American College of Cardiology (ACC) and American Heart Association (AHA) have released updated guidelines for the management of acute coronary syndromes (ACS). Dual antiplatelet therapy is recommended for at least 12 months in patients with ACS not at high bleeding risk, with ticagrelor or prasugrel preferred over clopidogrel in those undergoing percutaneous coronary intervention (PCI). High-intensity statin therapy is recommended for all patients with ACS. For STEMI, primary PCI is recommended, with fibrinolytic therapy offered within 12 hours when the anticipated delay to primary PCI exceeds 120 minutes. Rescue PCI is recommended after failed fibrinolysis. For procedural considerations, the radial approach is recommended over the femoral approach, intracoronary imaging is recommended during PCI for complex lesions, and routine manual aspiration thrombectomy should be avoided. Non-infarct-related artery PCI after the index procedure is recommended over a staged approach in selected stable patients with multivessel disease. .

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of ST-elevation myocardial infarction are prepared by our editorial team based on guidelines from the Society for Cardiovascular Angiography and Interventions (SCAI/NAEMSP/AHA/ACC/ACEP 2025), the American Academy of Family Physicians (AAFP 2024), the American College of Chest Physicians (ACCP 2024), the Canadian Cardiovascular Society (CCS/CAIC 2024), the European Society of Cardiology (ESC/EACTS ...
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Screening and diagnosis

Diagnosis: as per ESC 2023 guidelines, base the diagnosis and initial short-term risk stratification of ACS on a combination of clinical history, symptoms, vital signs, other physical findings, ECG, and high-sensitivity cardiac troponin.
B
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Classification and risk stratification

Prognostic assessment: as per AAFP 2024 guidelines, refer patients presenting with acute chest pain and high suspicion of ACS to the emergency department and use predictive risk scores there to aid in the prognosis, diagnosis, and management.
B
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Diagnostic investigations

History and physical examination: as per AAFP 2024 guidelines, elicit medical history and perform a physical examination in patients presenting with acute chest pain and high suspicion of ACS.
B
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  • ECG

  • Echocardiogram

  • Cardiac troponin

  • Coronary CTA

  • Cardiac MRI

  • Lipid profile

Diagnostic procedures

Coronary angiography: as per AAFP 2024 guidelines, perform coronary angiography in patients with STEMI followed by PCI with a drug-eluting stent within 120 minutes of presenting to the emergency department.
A
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Respiratory support

Supplemental oxygen
As per ACC/ACEP/AHA/…/SCAI 2025 guidelines:
Administer supplemental oxygen in patients with ACS and confirmed hypoxia (oxygen saturation < 90%) to increase oxygen saturations to ≥ 90% in order to improve myocardial oxygen supply and decrease anginal symptoms.
B
Do not routinely administer supplemental oxygen in patients with ACS and oxygen saturations ≥ 90%, as it does not improve cardiovascular outcomes.
D
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Medical management

Transfer: as per ACC/ACEP/AHA/…/SCAI 2025 guidelines, arrange immediate emergency medical services transport for patients with suspected STEMI to a PCI-capable hospital for primary PCI, aiming for a first medical contact to first-device time of ≤ 90 minutes.
B
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  • Shared-decision making

  • Fibrinolytic therapy (administration)

  • Fibrinolytic therapy (post-treatment transfer)

  • Antiplatelet therapy (aspirin)

  • Antiplatelet therapy (P2Y12 inhibitors, initiation)

  • Antiplatelet therapy (P2Y12 inhibitors, maintenance and de-escalation)

  • Antiplatelet therapy (intravenous GP IIb/IIIa inhibitors)

  • Anticoagulant therapy (general principles)

  • Anticoagulant therapy (with fibrinolysis)

  • Anticoagulant therapy (with revascularization)

  • Beta-blockers (IV)

  • Beta-blockers (PO)

  • RAS inhibitors

  • Mineralocorticoid receptor antagonists

  • Low-dose colchicine

  • Management of dyslipidemia

  • Management of ventricular arrhythmias (revascularization)

  • Management of ventricular arrhythmias (pharmacotherapy)

  • Management of ventricular arrhythmias (transvenous pacing)

  • Management of ventricular arrhythmias (radiofrequency ablation)

  • Management of ventricular arrhythmias (ICD)

  • Management of bradyarrhythmias

  • Management of AF (rate control)

  • Management of AF (rhythm control)

  • Management of AF (antithrombotic therapy)

  • Management of LV thrombus

  • Management of acute HF

  • Management of cardiogenic shock (setting of care)

  • Management of cardiogenic shock (coronary angiography and revascularization)

  • Management of cardiogenic shock (fibrinolysis)

  • Management of cardiogenic shock (intra-aortic balloon counterpulsation)

  • Management of cardiogenic shock (mechanical circulatory support)

  • Management of cardiac arrest (post-resuscitation evaluation)

  • Management of cardiac arrest (temperature management)

  • Management of cardiac arrest (revascularization)

  • Management of pain and anxiety

Inpatient care

Setting of monitoring: as per ACC/ACEP/AHA/…/SCAI 2025 guidelines, offer telemetry monitoring in patients with ACS to reduce cardiovascular events, with the duration determined by cardiac risk.
B
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  • ECG monitoring

  • Imaging monitoring

Nonpharmacologic interventions

Lifestyle modifications: as per ESC 2023 guidelines, advise adopting a healthy lifestyle, including smoking cessation, healthy diet (Mediterranean style), alcohol restriction, regular aerobic physical activity and resistance exercise, and reduced sedentary time, in all patients with ACS.
B
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  • Smoking cessation

  • Psychological interventions

Therapeutic procedures

Indications for primary PCI: as per ACC/ACEP/AHA/…/SCAI 2025 guidelines, perform primary PCI in patients with STEMI presenting < 12 hours after symptom onset, aiming for a first medical contact to device activation time of ≤ 90 minutes, or ≤ 120 minutes in patients requiring hospital transfer, to improve survival.
A
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  • Indications for rescue PCI

  • Technical considerations for PCI (arterial approach)

  • Technical considerations for PCI (choice of stent)

  • Technical considerations for PCI (multivessel disease)

  • Technical considerations for PCI (aspiration thrombectomy)

  • Technical considerations for PCI (intravascular imaging)

  • Technical considerations for PCI (hemodynamic support device)

  • RBC transfusion

Perioperative care

General principles
As per ACC/AHA/SCAI 2022 guidelines:
Establish multidisciplinary, evidence-based perioperative management programs to optimize analgesia, minimize opioid exposure, prevent complications and to reduce time to extubation, length of stay, and healthcare costs in patients undergoing CABG.
B
Ensure a comprehensive approach to reduce sternal wound infection in patients undergoing CABG.
B
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  • Perioperative management of antithrombotics

  • Perioperative beta-blockers

  • Perioperative amiodarone

  • Intraoperative insulin infusion

Surgical interventions

Indications for CABG: as per ACC/ACEP/AHA/…/SCAI 2025 guidelines, consider performing emergency or urgent CABG surgery in patients with STEMI in whom PCI is not feasible or successful, with a large area of myocardium at risk, to improve clinical outcomes.
C
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  • Bypass conduits

  • Cardiopulmonary bypass

Specific circumstances

Pregnant patients: as per ACC/AHA/SCAI 2022 guidelines, consider performing primary PCI as the preferred revascularization strategy in pregnant patients with STEMI not caused by spontaneous coronary artery dissection.
C
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  • Elderly patients

  • Patients with CKD

  • Patients with diabetes mellitus

  • Patients with cancer

  • Patients scheduled for noncardiac surgery

  • Patients with spontaneous coronary artery dissection

  • Patients with MINOCA

Patient education

Patient-centered care: as per ESC 2023 guidelines, provide patient-centered care by assessing and adhering to individual patient preferences, needs, and beliefs, ensuring that patient values are used to inform all clinical decisions.
B
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Preventative measures

Low-dose aspirin
As per CAIC/CCS 2024 guidelines:
Do not initiate aspirin routinely for primary prevention of ASCVD in patients without ASCVD, regardless of sex, age, or diabetes status.
D
Consider initiating aspirin for primary prevention of ASCVD in certain patients deemed at high risk of ASCVD but with low bleeding risk in the context of a patient-centered and informed shared decision-making process.
E
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  • Statin therapy

  • Influenza immunization

Follow-up and surveillance

Cardiac rehabilitation
As per ACC/ACEP/AHA/…/SCAI 2025 guidelines:
Refer patients with ACS to an outpatient cardiac rehabilitation program prior to hospital discharge to reduce death, myocardial infarction, hospital readmissions, and improve functional status and QoL.
A
Consider offering a home-based cardiac rehabilitation program as a reasonable alternative to a center-based program in patients with ACS to improve functional status and QoL.
C
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  • Lipid monitoring

  • Follow-up imaging

  • Management of post-STEMI pericarditis

Quality improvement

Healthcare system and hospital requirements, pre-hospital settings: as per ACC/ACEP/AHA/…/SCAI 2025 guidelines, ensure that all communities create and maintain regional systems of STEMI care that coordinate prehospital and hospital-based care processes to reduce total ischemic time and improve survival in patients with STEMI.
B
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  • Healthcare system and hospital requirements (hospital settings)